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Relapsed, resistant and untreated congenital talipes equinovarus poses significant challenges in view of functional outcome following conventional serial casting and soft tissue release procedures. The Ilizarov ring fixator here offers significant possibilities as an extended conservative treatment modality. The aim of the present study was to critically evaluate effectiveness of the Ilizarov ring fixator with regard to radiological, clinical and functional outcome, in the difficult clubfeet. The study was carried out on patients presenting with relapsed, resistant or untreated congenital talipes equinovarus deformity, who underwent deformity correction using the Ilizarov ring fixator application. All patients were reviewed at 6 monthly intervals for over 3 years following fixator removal with an objective clinical, radiological and functional assessment. Twenty-three patients with 30 clubfeet were enrolled in our study. The mean age was 8.3 +/- 3.6 (range 4 to 17) years. The postoperative clinical, radiological and functional scores showed statistically significant improvement among all patients when compared with the pre-operative data. All 30 feet developed varying complications during treatment with pin track infections being the most common. However, they were managed while continuing the distraction correction process. The Ilizarov ring fixator is an effective and reliable solution for difficult and challenging clubfeet. However, one must be aware of a strict adherence to a bracing protocol to avoid recurrence of deformities. A regular periodical functional and clinical follow up must be ensured among these children for a favourable outcome. Level of clinical evidence: 3

Introduction Congenital dislocation of the knee (CDK) is a rare condition and includes a characteristic hyperextension deformity at the knee with varying degrees of anterior and lateral subluxation. Developmental dysplasia of the hip (DDH) is a common disorder and presents frequently to a pediatrician. DDH with CDK is common, but hip pathology usually remains unnoticed because of more obvious deformity at the knee. Through this case, we aim to highlight the association of CDK with DDH and discuss its management. Case Presentation A preterm, 31-week baby girl, appropriate for gestational age, delivered to a primigravida mother with early antenatal oligohydramnios. At birth, the baby had an externally rotated left lower limb and the knee in hyperextension. A clinical diagnosis of CDK with ipsilateral DDH was confirmed further with a radiological evaluation of the left hip and knee. Staged correction of deformities was done starting with the knee, followed by the hip joint. By the 12th week of life, the knee and hip dislocations were corrected satisfactorily, which remained stable till the last follow-up (6 months). Conclusion CDK can present with an ipsilateral DDH, and this possibility needs attention. Newborns having congenital knee dislocation should undergo hip screening for instability by clinical methods. Ultrasound screening of the hip can be done if clinical examination is inconclusive. Such cases can be managed successfully by staged knee and hip disorder correction.

Paediatric femur neck fracture is an uncommon injury and is known for high rate of complications. This in turn, can have significant impact on development of hip and overall function of the child. Controversy prevails in many areas of management and it still remains a difficult injury to manage. Through this paper, an attempt has been made to summarize the current concepts in management and suggest current recommendations regarding the controversies so that these injuries can be managed judiciously. A systematic review was done as per PRISMA guidelines using pre-defined inclusion and exclusion criteria. 18 studies with better scientific evidence after quality assessment were included in the systematic review. Current trends and Controversial issues in management were then identified and discussed. It was observed that existing literature is inconclusive regarding several aspects of management of this injury with no clear guideline available. However, certain recommendations useful for decision making could be made. These injuries should be managed aggressively with operative fixation at the earliest and one should not hesitate to open reduce if acceptable alignment is not obtained after one or two gentle closed manipulations. Choice of implant and their configuration in neck can vary depending on age and weight of patient, type of injury and surgeon’s preference. Initial fracture displacement could be considered to be most predictive for development of osteonecrosis of the femoral head, whereas, role of surgical decompression, type of fixation and timing of surgery is still debatable. Functional outcome is primarily affected by osteonecrosis of the femoral head, nonunion and severe coxa vara, whereas mild coxa vara, shortening, and premature closure of physis when considered alone, don’t have significant influence on functional outcome in short term. Treatment of fracture neck femur in children is still controversial in many aspects and needs further research. It should be understood that complications can occur regardless of the method of treatment and might reveal their full impact many years after injury. Hence, a guarded prognosis should be explained to the parents and care-givers at the time of injury.

PURPOSE: To identify literature on variations and knowledge gaps in the incidence, diagnosis, and management of developmental dysplasia of hip (DDH) in India. METHODS: Following standard methodology and PRISMA-ScR guidelines, a scoping systematic review of literature on incidence, diagnosis, and treatment of DDH in India was conducted. Studies conducted in India, published in indexed or non-indexed journals between 1975 and March 2021, were included in the search. RESULTS: Of 57 articles which met the inclusion criteria, only 33 studies (57.8%) were PubMed-indexed. Twenty-eight studies (49%) were published in Orthopaedic journals and majority had orthopaedic surgeon as the lead author (59.6%). Sixteen studies were mainly epidemiological, 20 reported screening/diagnosis, and 21 reported treatment of DDH. Almost 90% of the studies (51) were Level 4 or 5 according to the levels of evidence in research. There is lack of clarity in the definition of hip dysplasia and screening/diagnostic guidelines to be used. The incidence of hip dysplasia in India is reported to be 0–75 per 1000 live births, with true DDH between 0 and 2.6/1000. Late-presenting DDH is common in India, with most studies reporting a mean age of > 20 months for children presenting for treatment. The treatment is also varied and there is no clear evidence-based approach to various treatment options, with lack of long-term studies. CONCLUSION: This systematic scoping review highlights various knowledge gaps pertaining to DDH diagnosis and management in India. High-quality, multicentric research in identified gap areas, with long-term follow-up, is desired in future.

Background Cephalomedullary nails are presently the gold standard in management of unstable trochanteric fractures. The tip-apex distance (TAD) is one of the most important factors that determines success or failure of fixation, but was described originally in context of an extramedullary hip screw. Cephalomedullary nails use a different biomechanical approach to fixation; and it is hypothesized that the TAD rule may not apply similarly with these. The aim of this study is to assess whether a high TAD correlates with poor outcomes with cephalomedullary nails, and to elucidate other factors that may predict such outcome. Methods We retrospectively reviewed the clinical and radiographic records of patients with intertrochanteric fractures, treated at our institution over a 2-year period. Those with unstable fractures (31.A2 and 31.A3), and who were treated with cephalomedullary nails were included in the study. The TAD and the position of the device in the femoral head (Cleveland index) were assessed. Other factors that could influence outcome like age, gender, AO fracture type, restoration of neck-shaft angle and degree of osteoporosis were analysed. Radiographic records of up-to at-least 3 months post-operatively were assessed for complications. Results After applying the exclusion criteria, 75 patients were included in the analysis. The overall rate of complications was 12%. They occurred in two major patterns - varus collapse and cut-out occurred in 5 patients (6.67%), and device migration in 4 patients (5.33%). The average TAD of patients with cut-out was 28.78 mm, compared to 19.44 mm in those without cut-out (p = 0.002). Our data predicted a cut-off TAD >23.56 mm as most significant for cut-out with cephalomedullary nails. On univariate logistic regression, high TAD (p = 0.009), sub-optimal device positioning (p = 0.02) and poor restoration of neck-shaft angle (p = 0.04) were found to be significant for varus collapse and cut-out, but not for complications relating to device migration. On multivariate analysis, none of the above factors reached statistical significance in isolation. Conclusion As with extramedullary devices, TAD, along with sub-optimal device positioning and poor restoration of neck-shaft angle is a useful predictor of cut-out even with cephalomedullary nails, negating the initial hypothesis. The above factors in combination have a more significant effect than any one factor in isolation to cause varus collapse and implant cut-out. However these do not affect Z effect, reverse Z effect or other types of device migration seen especially with dual-screw nails.

BACKGROUND: Developmental dysplasia of hip (DDH) is a common disorder of childhood and has a good prognosis when treated at an early age. In spite of being a significant concern, many children with DDH are not picked early and present late at walking age. In our country, it is presumed to be due to absence of a national policy for screening of DDH. Screening programmes including the combination of clinical and radiological methods in different ways have been suggested. However, the exact method of screening is controversial. PURPOSE: To analyze effectiveness and cost-effectiveness of various screening methods for DDH. STUDY DESIGN: Systematic review. METHODS: This review was conducted in accordance with PRISMA guidelines. Medline database was explored for original case series and randomized clinical trials. Inclusion criteria were English language, screening for DDH in neonates, sample size more than 500, and studies with minimum duration of one year. RESULTS: Thirty-four studies were selected to write the manuscript. This included 23 studies looking for effectiveness of a screening programme and 11 studies comparing various outcomes of different screening strategies. A trend favoring universal ultrasound screening was observed CONCLUSION: The literature supports universal ultrasound screening and has proved its cost-effectiveness. However, considering the logistic and financial challenges in our country, immediate implementation of universal ultrasound screening seems impractical. In the absence of any current guidelines for screening for DDH in India, we suggest professional organizations involved in the care of children and public health policy-makers to come together to develop national screening guidelines for DDH.

© 2020 Elsevier Ltd Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p

Scapular osteochondroma can have unusual manifestations like pseudo-winging and snapping syndrome in ventrally located lesions. Dorsally located lesions cause a cosmetic blemish and difficulty in lying supine. We present a series of 3 cases of scapular osteochondroma with varying presentations. One was a ventral surface (subscapular) osteochondroma which presented with pseudo winging and snapping syndrome and 2 were dorsal surface osteochondromas which presented with prominence at the back and difficulty in lying supine. All were treated surgically with good functional and cosmetic results. Surgical resection of tumor is the treatment of choice. An appropriate surgical approach should be chosen depending on the location of tumor. We propose the use of trapezius sparing approach and splitting the scapular apophysis for subscapular osteochondroma in children as it produces less soft tissue damage, is easy to repair and allows early rehabilitation.

The traditional treatment of the hip with a slip of the capital femoral epiphysis has been an in situ fixation using a single screw. This has the sanctity of a long term result. Recent literature stresses the outcomes of failure to restore the upper femoral alignment and on the basis of the poor results makes a plea for capital realignment. This being a recent development, it lacks the support of long term follow up and it remains to be seen if this is a better alternative of managing displaced and unstable slipped capital femoral epiphysis. The authors look at some of the available literature on the subject to highlight these controversies and their implications for orthopedic surgeons. Other controversies pertain to contralateral fixation, duration of immobilization and amount of weight bearing after an in situ fixation.